Esophagogastroduodenoscopy

CHAPTER 101 Esophagogastroduodenoscopy

Edward G. Zurad

During the past four decades, performing flexible fiberoptic esophagogastroduodenoscopy (EGD), or gastroscopy, has revealed a myriad of diseases and conditions of the upper gastrointestinal tract to primary care physicians, surgeons, and gastroenterologists. Refinements in equipment and technology have dramatically improved endoscopic diagnosis. Advancements have also permitted any interested physician, in a variety of settings, to evaluate and treat patients with both simple and complex problems of the esophagus, stomach, and the duodenum. Rapid diagnosis of upper gastrointestinal (GI) pathology with appropriate pharmaceutical and surgical management assures a high level of cost-effective care that any primary care physician can provide.

EGD is relatively quick and can be completed within 5 to 20 minutes. The procedure can be performed in various clinical environments, including the office, outpatient endoscopic suite, the hospital, or surgical center. The procedure can even be completed in the intensive care unit (ICU) or emergency room (ER) setting with a portable endoscopy cart. One study (Rodney and colleagues, 1990) indicated that when primary physicians performed EGD, it was associated with enhanced management and improved diagnostic accuracy in 89% of cases. Primary care physicians now perform flexible sigmoidoscopy, EGD, and colonoscopy on an increasingly frequent basis in their offices.

In EGD, a small flexible endoscope is introduced through the mouth (or with newer thinner diameter scopes, through the nose) and advanced through the pharynx, esophagus, stomach, and usually into the second portion of the duodenum. Both the fiberoptic and video gastroscopes are similar in construction to the flexible sigmoidoscope, the device with which many primary care physicians began to develop skills over the past three decades. Most modern endoscopes use a video chip (charge coupled device) for improved and more definitive imaging, as opposed to the older endoscopes, in which fiberoptics are used for image transmission. The tip of the scope can be moved in multiple directions. The endoscope has channels for air insufflation, air aspiration, biopsy, and water instillation.

The procedure is usually performed while the patient is under conscious sedation, although it can be completed with only topical anesthesia (a common practice in Asia). General anesthesia is reserved for a select group of patients who are difficult to sedate because of chronic narcotic drug usage or who may have allergies to the very effective agents now available for conscious sedation.

The EGD technique is also utilized when performing endoscopic ultrasound (EUS) and endoscopic interventions that are outside the realm of this chapter, including endoscopic retrograde cholangiopancreatography (ERCP) and transthoracic echocardiography.

Indications

Symptoms

In many instances, it is one of the following symptoms that prompt the physician’s decision to consider an EGD:

• Dyspepsia (abdominal pain)

• Dysphagia (difficulty swallowing)

• Odynophagia (painful swallowing)

• Early satiety

• Recurrent regurgitation or gastroesophageal reflux disease (GERD)

• Epigastric pain

• When swallowing, sensation of food sticking or a foreign body

• Meal-related heartburn

• Severe indigestion

• Chronic nausea and vomiting

• Substernal or paraxiphoid pain

• Severe weight loss

• Persistent anorexia

• Noncardiac chest pain

Because over-the counter (OTC) proton pump inhibitors (PPIs) and histamine-2 (H₂) antagonist therapy are available, many patients independently initiate therapy for their upper gastrointestinal symptoms. They present to their primary care physician only after failing a self-directed trial of PPIs or H₂ antagonists. In addition, many patients have tried antacids or other agents for their upper gastrointestinal symptoms that have failed, which results in their concern for detection of the etiology of recalcitrant symptoms. EGD provides a precise evaluation to obtain a direct endoscopic assessment of the esophagus, stomach, and duodenum. Furthermore, EGD permits the physician to retrieve tissue specimens for pathologic analysis during this brief invasive procedure, which is of increasing importance.

Signs

• Unexplained anemia

• Gross or occult gastrointestinal bleeding

• Radiographic abnormality of the upper GI tract

• Weight loss

• Abdominal mass

• Hematemesis

Contraindications

There are relatively few contraindications to the performance of EGD. The diameter of the currently available fiberoptic endoscopes is similar to the diameter of the nasogastric (NG) tubes that are inserted on a daily basis in most hospitals. The safety of the procedure is readily acknowledged. Most primary care physicians inserted NG tubes during their early medical school education and residency training. Recalling the simplicity of these early experiences should help clinicians feel more confident about the insertion of an EGD scope.

Contraindications to EGD include the following.

Relative

Anticoagulants

Diagnostic EGD is considered a low-risk procedure for bleeding in patients taking anticoagulants and, therefore, can be performed without adjustment of anticoagulants prior to the procedure by physicians extremely familiar with EGD technique. Difficult or traumatic intubation of the scope could result in cricopharyngeal hematoma, which could theoretically cause carotid artery occlusion. A risk of retropharyngeal hematoma also may be present in patients with severe coagulation abnormalities.

If biopsy or polypectomy is contemplated, then the patient’s coagulation profile should be normalized. Certain therapeutic procedures (i.e., dilations, percutaneous gastrostomy, polypectomy, endoscopic sphincterotomy, EUS-guided fine-needle aspiration, laser ablation, coagulation) are considered high-risk procedures for bleeding, and adjustment of anticoagulation is required. The use of low-molecular-weight heparin bridge therapy may be necessary for individuals with chronic atrial fibrillation or valvular heart prostheses in order to prevent the risk of embolic events.

Equipment

Endoscopes are produced by several different manufacturers (e.g., Olympus, Pentax, Fujinon, Visions Sciences).

The typical esophagogastroscope consists of an “umbilical cord” (containing transmitted light and imaging capabilities), control head (with hand-operated wheels for up/down and left/right, air/water control buttons, and a suction button), and the long insertion tube, which is approximately 100 cm long and 7.8 to 11 mm wide. The bending section at the tip of the scope allows up to 180 degrees of deflection for retroflexion of the tip of the endoscope.

The endoscope contains a lumen for insufflation of air and water, a working channel of 2 to 3 mm diameter (larger channel diameter for therapeutic endoscopes) used for suctioning and passage of instruments, control wires for moving the tip of the endoscope, and the imaging system that is either fiberoptic (rare) or video (widely available). The endoscope light source and imaging source (either video monitor or direct-view through the eyepiece) are critical aspects of the scope. Images and video can be recorded and printed depending on the equipment used.

Flexible ultrathin fiberoptic and video endoscopes can be used without sedation for office-based EGD. Commonly used without conscious sedation, these endoscopes are inserted transnasally or perorally and have a working length of 925 to 1100 mm, an external diameter of 5.3 to 6 mm, and a working channel diameter of 2 mm. With interventional scopes, multiple instruments have been developed that can be introduced through the working channel of the endoscope. These instruments include biopsy forceps, snares, sclerotherapy needles, heater probes, electrocautery probes, balloon-dilation devices, nets, and baskets. Guidewires can be placed, and, when the endoscope is withdrawn, wire-guided bougie dilators can be utilized. Devices can also be placed onto the end of the endoscope for banding of esophageal varices and endoscopic mucosal resection.

Some of the newer endoscopes provide high resolution and magnification. Such scopes are used for the evaluation of certain upper gastrointestinal diseases. The upper endoscope is also used to guide endoscopic treatment of GERD, such as with the Bard EndoCinch endoscopic suturing device and the NDO full-thickness plicator. One of the more recent advances in video endoscopy is narrow band imaging (NBI). NBI uses optical filters and high relative intensity of blue light for imaging and assessment of mucosal morphology and topography, such as mucosal and superficial vascular patterns. NBI has been studied in patients with Barrett’s esophagus, early gastric tumors, and colorectal lesions and has had promising results. Its full clinical utility has yet to be realized. In addition to the endoscope, other important equipment should be in operational order prior to starting an EGD:

• Light source (halogen light source versus xenon)

• Camera source

• Color video printer

• Video monitor

• Video recorder

• Biopsy forceps/brush

• Endoscopy table/cart

• Intravenous (IV) stand and IV sets

• Mouth guard

• Stool with wheels for the endoscopist (if he or she sits during the performance of the procedure)

• Sphygmomanometer versus continuous blood pressure monitor

• Stethoscope

• Electrocardiogram (ECG) machine or continuous cardiac monitor

• Oxygen saturation monitor (pulse oximeter) (consider Welch Allyn system that performs all necessary monitoring functions)

• Dextrose 5% and 0.45% sodium chloride solution (1 L) or lactated Ringer’s solution

• Suction equipment and tubing

• Specimen jars with formalin solution

• Syringes and needles

• K-Y Jelly (water-soluble) scope lubricant

• Protective gloves (remember latex sensitivity in sensitive patients)

• Rapid urease test (CLO test) materials

• Anesthetic, sedative, and narcotic medications (see Chapter 2, Procedural Sedation and Analgesia)

• Oxygen and delivery mask or nasal cannula

• “Crash cart” supplies (consider the Banyan kit—“a crash cart in suitcase”—if procedure is being performed in the office)

• Toothpicks to remove tissue from biopsy forceps

• Dictation capabilities or computer for immediate completion of the procedural record

• Sink/supplies for cleaning the scope

Preprocedure Patient Preparation

As with any procedure, EGD needs to be explained to the patient in detail prior to the procedure. The possible risks, benefits, and complications must be reviewed. It is wise to include a patient education handout and instructions for the patient to follow before the procedure (see the patient education handout online at www.expertconsult.com). The patient should also be given a copy of these to take home to share with a spouse or other family members.

Informed consent must be obtained before performance of EGD (see the patient consent form online at www.expertconsult.com). A preprocedure video or DVD that the patient and spouse or family member can view will reduce anxiety regarding the upcoming EGD. This video, which can be obtained from various pharmaceutical companies free of charge, will also introduce the subject of conscious sedation and review contraindications to the procedure. Figures 101-1 to 101-6 show other helpful forms for office use.

Figure 101-1 Sample form of instruction guidelines for gastroscopy staff.

(From The Medical Procedures Center, Midland, Mich.)

Figure 101-2 Sample form for esophagogastroduodenoscopy (EGD) counseling.

(From The Medical Procedures Center, Midland, Mich.)

Figure 101-3 Sample form of monitoring instructions for gastroscopy staff.

(From Fleischer D: Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: Issues and guidelines. Gastrointest Endosc 35:262, 1989.)

Figure 101-4 Sample form of esophagogastroduodenoscopy (EGD) nursing checklist.

(From The Medical Procedures Center, Midland, Mich.)

Figure 101-5 Sample form for the esophagogastroduodenoscopy (EGD) procedure.

(From The Medical Procedures Center, Midland, Mich.)

Figure 101-6 Sample form detailing the role of the assistant.

(From The Medical Procedures Center, Midland, Mich.)

Antibiotic Prophylaxis

According to the latest American Heart Association guidelines, antibiotic prophylaxis for endoscopy with or without gastrointestinal biopsy is not recommended (see Chapter 221, Antibiotic Prophylaxis). No published data demonstrate a conclusive link between procedures of the GI tract and the development of bacterial endocarditis. No studies exist that demonstrate that the administration of antimicrobial prophylaxis prevents endocarditis in association with procedures performed on the upper GI tract.

Sedation

See Chapter 2, Procedural Sedation and Analgesia, and Chapter 7, Pediatric Sedation and Analgesia.

EGD has traditionally been performed in a hospital procedure room specializing in gastrointestinal disorders (a “GI suite”). It has also commonly been performed in an emergency room setting, an outpatient surgery facility, or a hospital operating room specially equipped for endoscopic procedures. Facility fee costs and sedation fees exceed physician reimbursement severalfold. Many physicians have completed the procedure in their offices simply using a topical anesthetic spray (Table 101-1).

TABLE 101-1 Drugs Used for Esophagogastroduodenoscopy

Medication	Dose
Narcotics
Meperidine (Demerol) IV	10–75 mg (0.5–1 mg/kg)
Fentanyl (Sublimaze) IV	1–2 mg
Butorphanol tartrate (Stadol Nasal Spray)	1–2 mg (1–2 sprays in nostril)
Propofol	Variable*
Benzodiazepines
Diazepam (Valium) IV	1–10 mg
Midazolam (Versed) IV	2–5 mg (0.035–0.1 mg/kg)
Lorazepam (Ativan) SL (onset in 10 min)	1–2 mg
Triazolam (Halcion) PO	0.5 mg
Anticholinergic
Glycopyrrolate (Robinul)	0.002 mg (0.01 mL/kg) IM 1 hour before procedure or 0.1 mg (0.5 mL) repeated every 2–3 minutes as needed
Miscellaneous
Simethicone (Mylicon) drops	0.6 mL (30–40 mg) in 30 mL of water PO (can also be flushed through the gastroscope with 5 mL of water)
Ketorolac (Toradol)	60 mg IM; 15 mg IV
Topical Local Anesthetics
Lidocaine 2% viscous solution gargle
Benzocaine 20% (Hurricaine) spray
Benzocaine 14% and tetracaine 2% (Cetacaine)
Antagonists
Naloxone (Narcan) IV	0.2–0.8 mg
Flumazenil (Romazicon) IV	0.2–1 mg (start with 0.2 mg; repeat every 60 sec. to a maximum of 1 mg or until reversal of benzodiazepine effect has been achieved)
Nalmefene hydrogen chloride (Revex)	1–2 mL IV

IM, intramuscular; IV, intravenous; PO, orally; SL, sublingually.

* Sedation may be initiated by infusing propofol at 100 to 150 mcg/kg/min (6 to 9 mg/kg/h) for a period of 3 to 5 minutes and titrating to the desired clinical effect while closely monitoring respiratory function.

Most physicians who perform EGD in their offices use a combination of a benzodiazepine and a narcotic to achieve appropriate sedation and pain control for EGD. An angiocath is usually placed when IV medications are to be used during the performance of EGD. The angiocath is connected to an IV line with IV fluids that are usually composed of D₅ (5% dextrose and one half normal saline) and normal saline. It is essential that resuscitation equipment and reversal drugs are readily available throughout the course of the procedure.

Many endoscopists now routinely use oxygen delivered through nasal cannula at 2 L/min to prevent any likelihood of hypoxemia that can occur during EGD, resulting from the mechanical nature of the tube in the upper airway region. This allows for a continuous source of oxygen delivery. The patient can be stimulated to inhale by simply advising him or her to take a deep breath. If oxygen is not used in a continuous fashion during the performance of the procedure, oxygen must be available in the event that hypoxemia occurs.

Midazolam (Versed) is a sedative/hypnotic commonly used for sedation. The peak effect of midazolam is seen within 3 to 5 minutes. It has a duration of action of 1 to 3 hours. Some of the major adverse effects include respiratory depression, hypotension, and rarely seen paradoxic agitation. The typical starting dose is 0.5 to 1 mg IV, which can be titrated to achieve a desirable level of sedation (usually in 1-mg increments every 2–3 minutes). Lower doses of midazolam should be administered to elderly patients with cardiopulmonary problems to avoid serious respiratory depression.

Diazepam (Valium) may be used instead of midazolam for sedation during EGD, but many centers prefer midazolam (over diazepam) because of its well-received amnestic effect and reduced tendency to cause local vein phlebitis. Diazepam is initiated at 1 to 2 mg IV and titrated at 2-mg doses given every 1 to 2 minutes. This agent can also cause respiratory depression and should be used carefully in elderly patients. Paradoxic excitation can be seen with this sedative.

Benzodiazepines can rarely cause paradoxic excitement. If it occurs, however, pure narcotics can usually be used to complete the procedure. In extreme cases cancel the procedure and reschedule it when assistance with sedation is available.

Meperidine (Demerol) is a narcotic analgesic that has mild sedative properties, slow onset of action, long duration, and long recovery time. When coadministered with benzodiazepines, potential complications include respiratory depression and sedation. The peak effect of meperidine is approximately 10 minutes, with a duration of action of 2 to 3 hours. Adverse effects include respiratory depression, hypotension, nausea, and vomiting. The typical starting dose is 12.5 to 50 mg IV, with subsequent doses not to exceed 25 mg/dose.

Fentanyl (Sublimaze) is a mildly sedative narcotic analgesic that has a rapid onset of action and short recovery time. In many endoscopy centers, fentanyl is the preferred agent for outpatient EGD. The peak effect is 5 to 8 minutes, and the duration of action is 1 to 3 hours. One of the major adverse effects is respiratory depression. The typical starting dose is 0.03 to 0.1 mg IV, with subsequent doses of 0.02 to 0.05 mg/dose.

When IV sedation is used, the end point to be titrated is slurred speech with the patient still able to be aroused.

Several agents are used as reversal agents for conscious sedation. Physicians employing conscious sedation should be very familiar with these agents. Naloxone (Narcan) reverses opioid-induced analgesia, central nervous system (CNS) effects, and respiratory depression. Naloxone has a peak effect of 1 to 2 minutes and a potential duration of action of 1 to 3 hours. Adverse effects include pain, agitation, nausea, vomiting, arrhythmias, sudden death, pulmonary edema, and withdrawal syndrome in patients with chronic opioid abuse. The typical dose is 0.04 mg IV for reversal of analgesia/sedation and 0.4 mg for narcotic overdose and respiratory arrest.

Flumazenil (Romazicon) is typically used for reversal of benzodiazepine-induced sedation and respiratory depression. Flumazenil has a peak effect of 3 to 5 minutes and a duration of action of 1 to 2 hours. Potential adverse effects include resedation and seizures. The typical dose is 0.2 to 0.5 mg IV for reversal of sedation (up to 1 mg total) and 1 to 3 mg IV for benzodiazepine overdose. This agent must be used with care in patients who are chronic anxiolytic users because it could cause the onset of seizures.

The use of monitored anesthesia care (MAC) and propofol (Diprivan) has developed widespread patient acceptance because of the short recovery time required for the patient. Such an approach is typically utilized in outpatient surgical centers, hospitals, or GI endoscopic suites. Many institutions have special guidelines regarding the use of propofol due to its possible potent adverse effects, which include apnea and hypopnea.

Sufficient anesthesia or sedation can often be accomplished without IV drug administration, using new approaches that are called non-IV conscious sedation. With this technique, a patient can be given diazepam 10 mg orally 1 hour before the procedure, or lorazepam 1 to 2 mg sublingually 30 to 60 minutes before the procedure. Halcion, 0.5 mg orally, can also be used. An optional intramuscular dose of ketorolac (Toradol) 60 mg may be given 30 to 60 minutes before the procedure.

Butorphanol tartrate (Stadol), 1 to 2 sprays (intranasally), can be added if needed to the preceding regimen, or used alone. It generally provides both sedation and analgesia sufficient to carry out EGD. In many countries, EGD is performed with topical anesthesia only. Topical anesthesia with a benzocaine and tetracaine mixture (Cetacaine) or lidocaine has the advantages of requiring less time for the overall procedure, eliminating the risks of conscious sedation, and decreasing the cost of the procedure by reducing or eliminating recovery time and nursing staff and anesthesia personnel. The spray is directed toward the posterior osopharynx while advising the patient to avoid breathing during the application. Inhaling the spray can cause significant coughing and gagging.

The disadvantages of using only topical anesthesia are patient discomfort and problems in performing the procedure on an uncooperative patient. An alternative choice for topical anesthesia is the “popsicle stick” method. In this scenario, lidocaine ointment (2%) is squeezed on a tongue blade that is covered with the patient’s favorite food flavoring, and this is placed into the back of the patient’s throat. The patient sucks on the tongue blade while vital signs are completed and the patient is prepared for the procedure. A tongue blade can be pressed into the posterior oral pharynx to ascertain that appropriate topical anesthesia has been obtained before insertion of the endoscope. Lack of a gag reflex ensures the desired effect. With the cost-saving trends in medicine, and with the newer, smaller scopes, EGD without sedation will likely become more commonplace in the future. With the introduction of the previously described smaller caliber endoscopes that can be passed through the nose, EGD without sedation may be more acceptable to patients.

Currently available small-diameter scopes allow for a comfortable examination with little manipulation or trauma to the cricopharyngeal region. As stated previously, the diameter of the scope is similar to that of an NG tube inserted daily by hospital nursing staffs.

It is important to select patients wisely for office-based EGD. This is a critical step. In individuals who are in the high-risk group (Box 101-1), the clinician should consider performing EGD in a facility where complications can be handled and more aggressive monitoring procedures can be carried out. The utilization of MAC is suggested in such cases.

Box 101-1 High-Risk Groups for Esophagogastroduodenoscopy

Agitated, uncooperative patient

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May 14, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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